for Local Health Officials

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1

Developed by the

Office of Scientific Integrity

Office of the Associate Director for Science

Office of the Director

Centers for Disease Control and Prevention

Department of Health and Human Services


August 1, 2012

Good
Decision Making in Real Time:

Practical Public Health Ethics

for Local Health
Officials


U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

2

Acknowledgements


Centers for Disease Control and Prevention


Drue Barrett


Gail Horlick


Michelle Houston


Lindsay Kramer


Kimberly
Lane


Julie Orta


Leonard
Ortmann


Ronald
Otten


National Association of County and City Health
Officials


Subha Chandar


Booz Allen Hamilton


Mark Ciampa


Erica Jeffreys


Carianne
Muse



Advisory Committee


Ruth
Gaare
Bernheim, University of VA


Alan Melnick, Local Health Director, OR


Matthew Stefanak, Local Health Director, OH


Case Developers


Elizabeth Fenton


Gail Horlick


JP
Leider


Stephanie Morain


Patricia
Sweeney


Public Health law Consultants


Matthew Penn, CDC Public Health Law
Program


Leslie Wolf, Georgia State University




3

Learning

Objectives


Through
this training, participants
will:



Gain
an overview of the basics of public health
ethics


Learn
how to apply ethics frameworks to public health decision
making


Learn
to apply public health ethics tools to address ethical challenges
that commonly arise in the practice of public
health


Explore
the overlap between ethics and
law


Examine
how the use of case studies can assist with exploring ethical
issues in public health
practice


Examine
specific ways to integrate ethical considerations in the day
-
to
-
day decision making in
health
departments



4

SECTION I:

INTRODUCTION TO

PUBLIC HEALTH ETHICS


5





What is Public Health Ethics?


6

Ethics and Morality

7

What

is Ethics?





8

What

is Ethics?



Identifying ethical principles to guide action


Analyzing and evaluating the rightness or
wrongness of particular actions


Ethics asks:


What choices should we make and why?


What moral norms should guide our actions?





9

Ethical Theories

Actor/Agent

Action


(Deontology)

Results

(
Consequentialism)

Virtue Ethics (Aristotle)

Ethical Duties
(Kant)

Utilitarianism

(J.S. Mill)

Focuses on

what a person
of character would do


Determines what

action
best fulfills one’s duty

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character


A moral action fulfills
a
duty or obligation one
owes to oneself or society

A moral action
provides the
best net balance of benefits
over harms for most people

Useful to assess skills and
abilities needed for success

Duties
defined in terms of
moral principles or
maxims


Implicit in cost/benefit

or
risk/benefit assessments

Reliability, trustworthiness,

competence


Autonomy, justice, equity,

human

rights

Long

versus short
term

harms
and benefits, undue burdens

10


Fields of Ethics




Bioethics


T
he
study of
ethical issues brought about by advances in biology
and medicine


Clinical ethics


Analysis of ethical issues and dilemmas in clinical practice


Research
ethics


Protection of research subjects


(in compliance with the Common Rule)


Public health ethics


Practical decision making that supports



public health’s mandate



11

Research Ethics and the Belmont Principles

Basic Ethical Principles


Respect for persons


Autonomy


Protection of those with diminished autonomy


Beneficence and
nonmaleficence


Do not harm


Maximize possible benefits and minimize possible harms


Justice


Giving persons what they deserve


Fair distribution of burdens and benefits



12

What is Public Health Ethics?


13

What is Public Health Ethics?




Ethical principles and moral norms particular to the
practice of public health


Study of or deliberation about moral norms that
should guide public health decision
-
making


A
process for identifying,
analyzing
, and resolving
ethical
conflicts or tensions
in public health


14

Clinical Ethics vs. Public Health Ethics

Clinical Ethics

Public

Health Ethics

Focus on individual patient
-
provider
interactions


Focus

on populations, institutions,
communities

Individual liberty, autonomy


Interdependence

of people

Authority

vested in prestige of
physicians and medical profession


Authority vested in the police powers
of states

Patient consent

Societal consent through the
political
process;
public engagement


Beneficence

and non
-
maleficence

Social good and avoiding social harm


Justice


Social justice and equity

15

Benefits of Public
Health
Ethics




Clarify, prioritize, and justify possible courses of
public health
action


Increased capacity to recognize ethical issues


Greater transparency in decision making


Foster respectful deliberation about ethical tensions


Enhanced public trust and relationship building


Strengthened scientific integrity and professional
excellence

16

What does Public Health Ethics Offer?


Vocabulary

and
guidance
: to illuminate the ethical
dimensions of cases and policies


Ethical principles and norms
: which are “starting
points” to guide ethical reflection about balancing
the competing moral claims


Balancing moral claims is similar to the process officials use in
understanding and making public health cost
-
benefit tradeoffs


Difference: Instead of focusing on “quantifiable” health gains or
losses, public health ethics focuses on identifying, weighing, and
balancing moral interests at stake in a particular situation

17

An Ethics Guide for

Public Health Decision Making


1.
Analyze ethical issues

2.
Evaluate
the
ethical dimensions
of the
alternate
courses
of
public health action

3.
Provide
justification
for
public health action




18

An Ethics Guide for Public Health

Decision Making


1. Analyze ethical issues


Risks and harms of concern?


Public health goals?


Moral claims of the stakeholders?


Is the source or scope of legal authority in question?


Are precedent cases relevant?


Do professional codes of ethics provide guidance?

19

An Ethics Guide for Public Health

Decision Making


2. Evaluate the ethical dimensions of the alternate
courses of public health action



Utility:
Does a particular public health action produce a balance of
benefits over harms?


Justice:
Are the benefits and burdens distributed fairly?


Respect for individual and community interests
:
Does the
public health action respect individual and civic roles and values
(e.g., honesty, trustworthiness)


20

An Ethics Guide for Public Health

Decision Making


3. Provide justification for public health action


Effectiveness:
Is the public health goal likely to be
accomplished?


Proportionality:
Will the probable benefits of the action
outweigh the infringed moral considerations?


Necessity:
Is overriding the conflicting ethical claims necessary
to achieve the public health goal?


Least infringement:
Is the action the least restrictive and least
intrusive?


Public justification:
Can public health agents offer public
justification that citizens, and in particular those most affected,
could find acceptable in principle?


21



Resource allocation


Negotiating the political context


Data use and management, including privacy and
confidentiality protection


Control of infectious diseases


Immigration


Community engagement


Balancing individual choice with protecting the
public good

Examples of Ethical Challenges Identified by
Public Health Officials

22





Questions?


23





Example of an Ethical Challenge in Public
Health Practice

24

Examples from Public Health Practice

Environmental health


Enforcing child lead poisoning prevention laws when families with
lead poisoned children lack the resources to remediate lead hazards
in their homes


25





Questions?


26





The Complementary Nature of Public Health
Law and Public Health Ethics


27

The
Complementary Roles of

Public
Health Ethics and Public Health Law


Why consider law in an ethics training?


Laws define
the boundaries
for lawful action


Laws may be a useful starting point for consideration
of public
health action


Laws may rely on common ethical principles


Laws may reveal social moral consensus


Laws and legal advice may provide the framework for decision
making



28

Ethics and Law Share
Similar

Decision Making Processes


Deliberate consideration and articulation of:


Facts, questions, conflict


Options


Decision


Reasons for the decision



And, in the end, reasonable minds may still disagree

29

Legal and Ethical Continuum


Ethical
ideals (best)


Ethical conduct (acceptable)



Possibly unethical conduct (questionable)

________________________________

LAW = generally agreed upon conduct;

unethical
conduct
≠ illegal
conduct




ethical
maximums







legal
minimums
(floor)

30

Key Concept: Police Powers


Defined: Powers exercised by the states to enact
legislation and promulgate regulations to protect the
public health, welfare, and morals, and to promote
the common good.


Examples:


Investigations of infectious disease outbreaks


Childhood vaccinations as condition for school entry


Ban on distribution of free cigarette samples in areas around
schools and other places frequented by minors


Involuntary detention of persons with certain communicable
diseases


Property seizure and destruction to control toxic substance
threats

31

Constitutional Limits on Government Action


Substantive limits
-

Jacobson v. Massachusetts

framework


Public health necessity


Reasonable means


Proportionality


Burden must be reasonable to anticipated benefit (least restrictive
alternative)


Harm avoidance


Should not impose undue health risk on the subject


Procedural limits


Due process requirements


Includes right to notice, hearing, representation of counsel, periodic
review

32

Parameter Setting Role of Law


Laws provide the boundaries


Tell you what you
must

do


Tell you what you
can

do


May be explicitly authorized in statute OR


May be inferred from statutes, case law


Tell you what you
cannot

do


But may not tell you what you
should

do (among
options)


In some cases, law may conflict with what
ought

to
do

33

Dealing with Uncertainty


Lawyer

may be unable to provide advice about what
one
ought

to do


Where law does not require or prohibit


And no legal precedent to guide


Limit of
professional

role



Ethics

may help in thinking through options


Identifying options


Delineating justification for or against

34

Summary


Law in Public Health:
Provides authority, limitations on
state power, incentives and disincentives for behavior;
often allows for much professional discretion


Ethics in Public Health:
Provides ongoing analysis,
deliberation about, and justification for public health
action and policy, often when law is indeterminate.



Law


Formal institution


Statutes


Regulations


Court decision


Public proceedings with a
“reasonable person”
standard

Ethics


Less formal


Moral norms, values


Professional codes


Previous cases


Publicly justifiable positions
based on ethical reasoning

35





Questions?


36





Example of an Ethical Challenge in Public
Health Practice

37

Examples from Public Health Practice


Multidrug resistant TB


Integrating ethics and legal powers to address the health needs
of the community while respecting rights of individuals and
families


38

Multidrug
Resistant TB Case



Family adopts several children from developing
country with endemic TB


Family has strong religious beliefs about medical
care; has refused immunizations


Children homeschooled


One of the adopted children, a teenager, develops a
cough and other symptoms


Pediatrician diagnoses active TB and notifies health
department


Health department intervenes …

39





Questions?


40





Practical Public Health Ethics Tools

for Making Tough Choices

41

Public Health Ethics Tools


Case

based approach


Stakeholder analysis


Deliberative process


Prioritizing values


Professional values
: Principles of the Ethical
Practice of Public Health


42

Case
-
based Approach


Traditional method of using cases to develop
practical moral judgment and resolve ethical issues



The case approach reasons “up” inductively from
particular instances to more generally applicable
moral conclusions



Similar to the development of common law which
uses legal precedents




43

Advantages of Case
-
based Approach


Encourages ethical reflection and
discussion


Reinforces basic ethical concepts through
application to concrete cases


Highlights practical
decision making


Allows learners to consider different perspectives


Sensitizes learners to complex, multi
-
dimensional
context of issues in public health practice




44

Stakeholder Analysis


Consider interests, values, and
moral claims of stakeholders


Identify potential partners and
areas of tension


May involve community
engagement or consultation






45

Deliberative Process


Ensures fairness of process


Weighs
stakeholder values in relation to core public
health values



Health


Community


Evidence
-
based decision making


Designs alternatives consistent with stakeholder and
public health values


Chooses between competing alternatives

46

Professional Values


Principles of the

Ethical
Practice of
Public
Health


Principles translate
values
into moral
rules for action



Emerged out of the practice
of public health



Key notion: the importance
of recognizing the
interdependence of
community members



47

Which Child Safety Seat is Best?

Most

Economical

Most

User
-
friendly

Most

Reliable

48

Prioritizing Values


No absolute best


Determining best depends on context


L
ocal circumstances


Stakeholder values


A decision always implies a prioritization of values


Ethical analysis makes implicit values explicit


Helps make decisions more transparent


Useful for justifying decisions, policies, recommendations





49

Values, Beliefs, and Key Assumptions of a
Public Health Perspective


Health



Interdependence



Community, collaboration and engagement



Science
-
based information for action

50

12 Ethical Principles

of the Practice of Public Health

51





Questions?


52

SECTION II:

TOPICS IN PUBLIC HEALTH
ETHICS: CASE STUDIES


53

Case Topics


Balancing the rights of individuals versus protecting the public
good (Module 1
)



Allocation of limited public health resources (Module 2
)



Protection of
underserved/marginalized
populations (Module 3
)



Protection of individual privacy and data confidentiality
(Module 4
)



Community engagement (Module 5)


54

General Instructions for Discussion of Cases


Structure of Cases


Background


Case description


Discussion questions


Read case out loud


Discuss initial reaction to case then proceed to
discussion
questions


Use “Ethical Analysis Framework” and “Principles of
the Ethical Practice of Public Health” as resource


Consider scenario shift if time allows

55

Group Discussion of Case

Childhood Obesity Educational Campaign




56

Small Group Discussion of Cases


Break into groups of 10


Identify a recorder and one member who will report
to the larger group when we reconvene


Take 30 minutes to discuss the case

57

Report from the Small Group Discussions

58

SECTION
III
:

IMPLEMENTING PUBLIC HEALTH
ETHICS IN YOUR HEALTH
DEPARTMENT


59

Implementing
Public Health Ethics

in your
Health Department



Ethics deliberative process



Networking
and
partnerships



Training
through
professional associations and
webinars



Resources (see Section IV
o
f student manual)


CDC Public Health Ethics Website


APHA Ethics Special Primary Interest
Group



60

For more information please contact Centers for Disease Control and
Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone, 1
-
800
-
CDC
-
INFO (232
-
4636)/TTY: 1
-
888
-
232
-
6348

E
-
mail: cdcinfo@cdc.gov

Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.

Questions?

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention